Washington State Association of Counties October 23, 2013 MaryAnne Lindeblad, Medicaid Director

1. Health System Transformationin Washington State Washington State Association of Counties October 23, 2013 MaryAnne Lindeblad, Medicaid Director Nathan Johnson, Division Director, Health Care Policy

2. Outline • HCA: Current State • ACA & Medicaid Expansion in Washington State • State Health Care Innovation Plan

3. HCA’s Role in Health Care • Washington State’s lead agency for health care policy • Largest health care purchaser in the state • Medicaid • Public Employees • Biennial budget: $13.4 billion • Post-ACA implementation will purchase health care for approximately 2 million Washington citizens • Mandate as prudent purchaser: The Triple Aim

4. HCA Medical Coverage Just over 1 million individuals receive their full medical coverage from Medicaid (excludes duals, partial duals, family planning-only and alien emergency medical.) • Current Health Plans • Amerigroup • Community Health Plan of Washington (CHPW) • Coordinated Care • Molina Healthcare • UnitedHealth Source: Medicaid Assistance Eligible Persons Report – Preliminary December Enrollment; Basic Health Monthly Enrollment December 2012

5. Health Reform: A System in Action Aug-Sept 2013:HCA’s launches community volunteer training Oct 1, 2013: Go Live Washington Healthplanfinder is operational for open enrollment. Mar-May 2013: OIC reviews plan filings Sept. 2013: HBEComprehensive Ad Campaign Begins June-July 2013: HCA launches Medicaid awareness and Apple Health outreach campaign Feb 2013HBE system Development and Unit Testing Jan 1, 2014: Coverage BeginsMedicaid expands to include newly eligible adults; Aug 2013: HBE In-Person Assistance system training begins Aug 2013: CMS begins national outreach; HBE’s1st advertising wave begins June 2013: HBE selects lead for in-person assisters Dec 31, 2014: HCAconversion to MAGI Medicaid complete for all eligible enrollees . • Aug-Dec 2012: HCAbegins Medicaid operational stakeholdering • Application Forms • Renewals Process • Quality Assurance • Client Letters May-July 2013: OIC reviews rate filings Jan-Dec 2014:HCA phased implementation of further systems features July 2013: HCA’sprimary care Medicaid rate increases (Jan 2013-Dec 2014). July 2013: DSHS upgrades WA Connection to accept premiums on line for CHIP, MEB and HWD. Oct 2013-Mar 2014: HBE’s initial open enrollment ends Mar 31 Awareness Enrollment Preparation

6. Health Care Coverage in 2014 New Continuum of Affordable Options *138% 185% 400% 300% % Federal Poverty Level 0%100%200%300%400% Medicaid (Adult Coverage) Medicaid (Pregnancy Coverage) n = ~750k Apple Health for Kids (Medicaid/CHIP) * Premium Tax Credits & Cost-Sharing Reductions for Exchange Health Plans Exchange Health Plans * The ACA’s “133% of the FPL” is effectively 138% of the FPL because of a 5% across-the-board income disregard 6

7. 2013 FPL Levels Source: http://aspe.hhs.gov/poverty/13poverty.cfm

8. Enrollment Ramp-Up: 2014-2016 Financial models assume Medicaid Expansion (newly eligible adults) and Welcome Mat (currently eligible but not enrolled) caseloads will ramp up over time. Based on: Buettgens, et al. The ACA Medicaid Expansion in Washington. The Urban Institute. 8

9. County-by-County, Medicaid Expansion Benefits Rural Areas 9

10. ~85% of Washington’s uninsured adults will have access to affordable coverage under full implementation of the ACA N = ~727,000 Source: Urban Institute Analysis of Augmented WA State Database

11. Uninsured Groups Remain • Undocumented immigrants • Individuals exempt from the mandate who choose to not be insured (e.g., because coverage not affordable) • Individuals subject to the mandate who do not enroll (and are therefore subject to the penalty) • Individuals who are eligible for Medicaid but do not enroll

12. April to September QHP Logo

13. Medicaid Enrollment Details

14. Our Future Challenge • Medicaid delivery system silos • Managed care, fee-for-service • County-based behavioral health • Dual-eligibles • Long-term care • Fragmented service delivery • Service needs & risk factors overlap in high-risk populations • Incentives &reimbursement structures not aligned to achieve outcomes Silos & Fragmented Care and aging of Washington’s population • Existing design not sustainable

15. Traditional “Solutions” • Cut people from care • Cut provider rates • Cut services • Increase cost sharing • Overlook pressing access issues There is a better way to drive improved value and achieve better health …the Washington Way.

16. Transformation in Washington State • Healthy people and communities • Better care • Affordable care for all Goals for Transformation

17. Washington State as First Mover • Reorient all state healthcare dollarsto pay for value rather than volume • Drive infrastructure and workforce improvements needed to achieve practice transformation and accountability for cost • Eliminate barriers to better health for people with physical and behavioral co-morbidities • Create greater local accountability and supportfor community health improvement and cross sector resource sharing

18. Where we are today:Strengths • Pioneering effortsin practice transformation, evidence-based medicine, patient centered medical home spread, and physical/behavioral health integration • Solid health information technology (HIT)and health information exchange (HIE) foundation • State leadership on health technology assessment, shared decision making • Collaborative organizations across the statefocused on clinical improvement, performance measurement, transparency and community solutions to care coordination, transitions and prevention

19. Where we are today: Gaps • Payment in Washington tends to be fee for service, incentivizes volume not value • Care delivery is highly fragmentedin most areas of the state • Population health approaches and community resources are not connected with care delivery

20. The Washington Way: Washington State will lead as a Purchaser and Market Organizer • Require all contractors providing state financed healthcare to: • Achieve progressively higher levels of value based payment methods that reward efficient and effective providers • Use a core set of measures • Be publicly accountable • Contribute data to all payer claims data base • Adopt recommendations of Dr. Robert Bree Collaborative and Health Technology Assessment Program • Use value based benefit design strategies • Include robust wellness components • Speak with one voice with other major state purchasers, both public and private

21. The Innovation Plan:Change how care is delivered and connected to communities • Aligning financial incentives • Using common measures and driving transparency • Enabling practice transformation • Strengthening our health information infrastructure • Modernizing our workforce • Providing people with access to tools and resources for health and wellness • Creating greater local accountability

22. The Innovation Plan:Health and Recovery • Achieve greater accountability for improved health outcomes and total cost of care • Foster strong and efficient primary care • Support effective care management and care transitions • Move care to less costly settings and methods • Reduce unwarranted variation and waste • Better integrate physical and behavioral health services and supports • Support evidence based practice and effective use of technology • Emphasize prevention and effective management of chronic illness

23. The Innovation Plan:System Supports Enhance data and information infrastructure • Planned build out of all payer claims database • Common statewide performance measures, transparency sensitive to rural/urban and populations served • Expanded health information exchange & shared care planning capabilities • Elimination or reduction of payment/administrative silos • Innovations in “geo-mapping” and hot-spotting to enable community focus on health inequities and targeted strategies and tactics and measure progress over time

24. The Innovation Plan:System Supports • Primary Health Regional Extension System • Hub – convener, coordinator, clearinghouse • Spokes within regions – local support for practice transformation and community priorities • Workforce Development & Support • Primary care loan repayment • Career ladder support • Community Health Worker • Tele-health services

25. Innovation Plan: Getting the Cogs to Move in Alignment Coordinate and integrate the delivery system with community services, social services and public health • Create 7-9 regional service areas • Accountable Community of Health organization within each region • Better cross sector alignment on statewide priorities • Local solutions thrive • Regional Extension Center “spoke” within each region • Medicaid procurement moves to these 7-9 regions • Align community service supports with regions over time • Transformation trust fund supports innovation

26. As a First Mover, the State will reorganize for “Local” health system transformation Nine Region Example 34

27. As a First Mover, the State will reorganize for “Local” health system transformation Seven Region Example 34

28. Accountable Communities of Health – The Washington Way • Philosophy and structure that recognizes the value of collective action and shared responsibility to achieve health • ACHs are formal entities – regionally governed, public-private partnership organizations ACH accountabilities • Develop a region wide health needs assessment, set common agenda • Act as the facilitator of learning and continuous quality • Fund manager and broker for aligned community initiatives • “Home” for shared services

29. The Washington Way: Bringing it all together: Physical and Behavioral Health Solutions “The evidence for integrated mental health care is now so extensive that researchers and policy makers urge that efforts be shifted from studying the approach to helping healthcare organizations implement it”. - University of Washington AIMs Center

30. The Washington Way: Bringing it all together: Physical and Behavioral Health Solutions • Restructure Medicaid procurement on a phased basis to better support integrated physical, mental health and substance abuse treatment & support services • Build and strengthen Washington’s Accountable Communities of Health infrastructure to support both integration, and upstream prevention • 3. Use existing and new state levers to spread and sustain integrated models of physical and behavioral health care • Practice transformation support and resources • Workforce capacity and flexibility • Shared clinical information sharing – new tools, resources and training • Outcome based payments to providers

31. The Big Picture for Washington Payment Linked to Outcomes Health Information Exchange & Shared Care Planning Healthy Communities Healthy People Performance Measurement & Transparency Practice Transformation Support Modified from “Framework for DE’s health transformation,” Delaware’s State Health Care Innovation Plan Workforce Capacity

32. Questions? MaryAnne Lindeblad Medicaid Director MaryAnne.Lindeblad@hca.wa.gov Nathan JohnsonDivision Director, Health Care Policy Nathan.Johnson@hca.wa.gov